Membership Application

Membership Application

This application is for individuals interested in participating in California Clubhouse programming.
California Clubhouse offers membership to individuals 18 years and older with a mental health diagnosis. We currently offer a Hybrid Program, in-person and virtual services. We require an application, eligibility form and an orientation to participate.

Eligibility form can be found by clicking here - Eligibility Form

All participation is voluntary and at no cost to members.
Name: *

First Name Last Name
Date Of Birth: *

Month Day Year
Date
Address:

Street Address

Street Address Line 2

City State

Zip Code Country
E-mail:
example@example.com
Phone Number:
How can we best contact you?

Primary Care Provider
The following can be contact information for your case manager, therapist, primary care provider.

All information will be kept confidential.
Agency:
Care Provider Name:

First Name Last Name
Address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

Membership Information:
To be eligible for California Clubhouse programs, members need to live in San Mateo County*, be 18 years of age or older, and have a diagnosis of Schizophrenia Disorder, Schizoaffective Disorder, Bipolar Disorder, Major Depressive Disorder, Anxiety Disorder, PTSD or Depression.

All information will be kept confidential.

*If you do not reside in San Mateo County, connect with us via email or phone.
Mental Health Diagnosis *

Schizophrenia Disorder Schizoaffective Disorder Bipolar Disorder Major Depressive Disorder Anxiety Disorder PTSD Other
Please confirm your age and county: *

I am 18 years or older I reside in San Mateo County
Signature *

Clear
Signature Date:

Month Day Year
Date
For more information about our program, feel free to visit our link tree page by clicking here - @californiaclubhouse
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